SYMPTOM SURVEY FORM:
Make a Phone Consult Appt. with Dr. Moffat
Patient name: ____________________________________
Date of Birth: ____________ Height: _______Weight: ______
Instructions: Number the boxes that apply to you. Use (1) for MILD symptoms (occur once or twice a month), (2) for MODERATE symptoms (occur several times a month), and (3) for SEVERE symptoms (you are aware of almost constantly). We are focusing only on those issues that you have been experiencing in the last SIX months. If there are symptoms that you have experienced in the past, please mark that box with the letters (Hx) which means historically experienced. If you can remember the approximate year, go ahead and write that after the symptom.
GROUP ONE: (Sympathetic Dominance)
1. |
Acid foods upset |
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2. |
Gets chilled, often |
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3. |
"Lump" in throat |
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4. |
Dry mouth-eyes-nose |
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5. |
Pulse speeds after meal |
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6. |
Keyed up - fail to calm |
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7. |
Cuts heal slowly |
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8. |
Gags easily |
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9. |
Unable to relax, startles easily |
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10. |
Extremities cold, clammy |
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11. |
Strong light irritates |
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12. |
Urine amount reduced |
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13. |
Heart pounds after retiring |
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14. |
"Nervous" stomach |
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15. |
Appetite reduced |
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16. |
Cold sweats often |
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17. |
Fever easily raised |
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18. |
Neuralgia-like pains |
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19. |
Staring, blinks little |
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20. |
Sour stomach frequent |
GROUP TWO: (Parasympathetic Dominance)
21. |
Joint stiffness after arising |
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22. |
Muscle-leg-toe cramps at night |
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23. |
"Butterfly" stomach, cramps |
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24. |
Eyes or nose watery |
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25. |
Eyes blink often |
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26. |
Eyelids swollen, puffy |
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27. |
Indigestion soon after meals |
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28. |
Always seem hungry; feels "lightheaded" often |
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29. |
Digestion rapid |
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30. |
Vomiting frequent |
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31. |
Hoarseness frequent |
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32. |
Breathing irregular |
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33. |
Pulse slow; feels "irregular" |
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34. |
Gagging reflex slow |
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35. |
Difficulty swallowing |
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36. |
Constipation, diarrhea alternating |
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37. |
"Slow starter" |
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38. |
Gets "chilled" infrequently |
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39. |
Perspires easily |
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40. |
Circulation poor, sensitive to cold |
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41. |
Subject to colds, asthma, bronchitis |
GROUP THREE (Sugar Handling)
42. |
Eats when nervous |
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43. |
Excessive appetite |
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44. |
Hungry between meals |
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45. |
Irritable before meals |
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46. |
Gets "shaky" if hungry |
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47. |
Fatigue, eating relieves |
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48. |
"Lightheaded" if meals delayed |
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49. |
Heart palpitates if meals missed or delayed |
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50. |
Afternoon headaches |
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51. |
Overeating sweets upsets |
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52. |
Awaken after few hours sleep-hard to get back to sleep |
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53. |
Craves candy or coffee in afternoons |
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54. |
Moods of depression-"blues" or melancholy |
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55. |
Abnormal craving for sweets or snacks |
GROUP FOUR (Cardiovascular)
56. |
Hands and feet go to sleep easily, numbness |
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57. |
Sighs frequently, "air hunger" |
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58. |
Aware of "breathing heavily" |
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59. |
High altitude discomfort |
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60. |
Opens windows in closed room |
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61. |
Susceptible to colds and fevers |
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62. |
Afternoon "yawner" |
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63. |
Gets "drowsy" often |
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64. |
Swollen ankles worse at night |
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65. |
Muscle cramps, worse during exercise; gets "charley horses" |
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66. |
Shortness of breath on exertion |
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67. |
Dull pain in chest or radiating into left arm, worse on exertion |
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68. |
Bruises easily, "black and blue" spots |
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69. |
Tendency to anemia |
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70. |
"Nose bleeds" frequent |
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71. |
Noises in head, or "ringing in ears" |
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72. |
Tension under the breastbone, or feeling of "tightness" worse on exertion |
GROUP FIVE (Liver and Gallbladder)
73. |
Dizziness |
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74. |
Dry skin |
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75. |
Burning feet |
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76. |
Blurred vision |
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77. |
Itching skin and feet |
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78. |
Excessive falling hair |
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79. |
Frequent skin rashes |
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80. |
Bitter, metallic taste in mouth in mornings |
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81. |
Bowel movements painful or difficult |
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82. |
Worrier, feels insecure |
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83. |
Feeling queasy; headache over eyes |
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84. |
Greasy foods upset |
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85. |
Stools light-colored |
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86. |
Skin peels on foot soles |
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87. |
Pain between shoulder blades |
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88. |
Uses laxatives |
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89. |
Stools alternate from soft to watery |
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90. |
History of gallbladder attacks or gallstones |
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91. |
Sneezing attacks |
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92. |
Dreaming, nightmare type bad dreams |
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93. |
Bad breath (halitosis) |
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94. |
Milk products cause distress |
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95. |
Sensitive to hot weather |
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96. |
Burning or itching anus |
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97. |
Craves sweets |
GROUP SIX (Digestion)
98. |
Loss of taste for meat |
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99. |
Lower bowel gas several hours after eating |
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100. |
Burning stomach sensations, eating relieves |
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101. |
Coated tongue |
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102. |
Pass large amounts of foul-smelling gas |
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103. |
Indigestion 1/2 - 1 hour after eating but sometimes up to 3-4 hours |
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104. |
Mucous colitis or "irritable bowel" |
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105. |
Gas shortly after eating |
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106. |
Stomach "bloating" after eating |
GROUP SEVEN (A) (Endocrine-Hyperthyroid)
107. |
Insomnia |
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108. |
Nervousness |
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109. |
Can't gain weight |
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110. |
Intolerance to heat |
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111. |
Highly emotional |
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112. |
Flushes easily |
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113. |
Night sweats |
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114. |
Thin, moist skin |
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115. |
Inward trembling |
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116. |
Heart palpitates |
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117. |
Increased appetite without weight gain |
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118. |
Pulse fast at rest |
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119. |
Eyelids and face twitch |
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120. |
Irritable and restless |
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121. |
Can't work under pressure |
GROUP SEVEN (B) (Endocrine-Hypothyroid)
122. |
Increase in weight |
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123. |
Decrease in appetite |
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124. |
Fatigues easily |
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125. |
Ringing in ears |
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126. |
Sleepy during day |
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127. |
Sensitive to cold |
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128. |
Dry or scaly skin |
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129. |
Constipation |
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130. |
Mental sluggishness |
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131. |
Hair coarse, falls out |
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132. |
Headaches upon arising-wears off during day |
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133. |
Slow pulse, below 65 |
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134. |
Increased frequency of urination |
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135. |
Impaired hearing |
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136. |
Reduced initiative |
GROUP SEVEN ( C ) (Endocrine-Hyperpituitary)
137. |
Failing memory |
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138. |
Low blood pressure |
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139. |
Increased sex drive |
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140. |
Headaches, "splitting or rendering" type |
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141. |
Decreased sugar tolerance |
GROUP SEVEN (D) (Endocrine-Hypopituitary)
142. |
Abnormal thirst |
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143. |
Bloating of abdomen |
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144. |
Weight gain around hips or waist |
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145. |
Sex drive reduced or lacking |
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146. |
Tendency to ulcers, colitis |
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147. |
Increased sugar tolerance |
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148. |
Women: menstrual disorders |
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149. |
Young girls: lack of menstrual function |
GROUP SEVEN (E) (Endocrine-Hyperadrenal)
150. |
Dizziness |
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151. |
Headaches |
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152. |
Hot flashes |
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153. |
Increased blood pressure |
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154. |
Hair growth on face or body (female) |
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155. |
Sugar in urine (not diabetes) |
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156. |
Masculine tendencies (female) |
GROUP SEVEN (F) (Endocrine-Hypoadrenal)
157. |
Weakness, dizziness |
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158. |
Chronic fatigue |
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159. |
Low blood pressure |
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160. |
Nails, weak, ridged |
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161. |
Tendency to hives |
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162. |
Arthritic tendencies |
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163. |
Perspiration increase |
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164. |
Bowel disorders |
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165. |
Poor circulation |
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166. |
Swollen ankles |
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167. |
Craves salt |
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168. |
Brown spots or bronzing of skin |
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169. |
Allergies-tendency to asthma |
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170. |
Weakness after colds, influenza |
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171. |
Exhaustion-muscular and nervous |
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172. |
Respiratory disorders |
GROUP EIGHT (B-Complex Deficiencies--Foundational Issues)
173. |
Apprehension |
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174. |
Irritability |
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175. |
Morbid fears |
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176. |
Never seems to get well |
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177. |
Forgetfulness |
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178. |
Indigestion |
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179. |
Poor appetite |
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180. |
Craving for sweets |
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181. |
Muscular soreness |
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182. |
Depression; feelings of dread |
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183. |
Noise sensitivity |
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184. |
Acoustic hallucinations |
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185. |
Tendency to cry without reason |
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186. |
Hair is coarse and/or thinning |
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187. |
Weakness |
|
188. |
Fatigue |
|
189. |
Skin sensitive to touch |
|
190. |
Tendency toward hives |
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191. |
Nervousness |
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192. |
Headache |
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193. |
Insomnia |
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194. |
Anxiety |
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195. |
Anorexia |
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196. |
Inability to concentrate; confusion |
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197. |
Frequent stuffy nose; sinus infections |
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198. |
Allergy to some foods |
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199. |
Loose joints |
FEMALE ONLY
200. |
Very easily fatigued |
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201. |
Premenstrual tension |
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202. |
Painful menses |
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203. |
Menstruates too frequently |
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204. |
Vaginal discharge |
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205. |
Hysterectomy/ovaries removed |
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206. |
Menopausal hot flashes |
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207. |
Menses scanty or missed |
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208. |
Acne, worse at menses |
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209. |
Depression of long standing |
MALE ONLY
210. |
Prostate trouble |
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211. |
Urination difficult or dribbling |
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212. |
Night urination frequent |
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213. |
Depression |
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214. |
Pain on inside of legs or heels |
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215. |
Feeling of incomplete bowel evacuation |
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216. |
Lack of energy |
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217. |
Migrating aches and pains |
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218. |
Tires too easily |
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219. |
Avoids activity |
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220. |
Leg nervousness at night |
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221. |
Diminished sex drive |
TO THE PATIENT: Please list below the five main physical complaints you have in order of their importance to you.
1. |
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2. |
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3. |
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4. |
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5. |
Make a Phone Consult Appt. with Dr. Moffat
For personal use only. Permission to make copies by you for you and your friends is granted. If you find this site to be of value, a donation of any amount would be greatly appreciated. You are encouraged to consult a knowledgeable practitioner before utilizing any of the information in this site. Thank you. Enjoy. Dr. Denice Moffat
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Dr. Denice Moffat |
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PO Box 9151 |
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Moscow, ID 83843 U.S.A |
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(208) 882-3993 Pacific time 9am to 6pm PST |
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